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Chapter • Subtotal Esophagectomy: Transhiatal Approach
Step8
Reconstruction
Gastric tube pull-through. In rare cases mobilization of the duodenum may be necessary (Kocher
maneuver) to lengthen the gastric tube.
Optional methods of placement:
Esophageal bed (
Retrosternal (. Fig. 11.11b)
Presternal (. Fig. 11.11c)
. Fig. 11.11a)
. Fig.11.11
Section II • Esophagus, Stomach, and Duodenum
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Step9
Cervical anastomosis
A two-layer anastomosis of the gastric tube and the esophageal stump is performed. e rst
seromuscular suture line is performed in an interrupted fashion (. Fig. 11.12a). e protruding
parts of the esophagus and the gastric tube are resected (
line of the posterior wall can be performed as a running suture (
lumen feeding tube is then inserted through the anastomosis and placed into the rst jejunal loop
for postoperative enteral nutrition (. Fig. 11.12d).
e anterior wall is completed with interrupted or running sutures. e second suture of
the anterior wall can be performed in a U-shaped fashion. is may provide an inversion of the
anastomosis into the gastric tube (
. Fig. 11.12e,f ).
. Fig. 11.12b). e second inner suture
. Fig. 11.12c). An enteral three-
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. Fig.11.12
Chapter • Subtotal Esophagectomy: Transhiatal Approach
Step10
Final situs
A so drain is placed dorsal to the anastomosis, followed by closure of the skin. Drainage of the
mediastinum is warranted by two so drains placed transabdominally and entering the mediastinum through the esophageal hiatus (
. Fig. 11.13).
. Fig.11.13
Standard Postoperative Investigations
Postoperative surveillance in intensive care unit
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“Generous” indication for postoperative endoscopy
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Daily check of the drainage for evidence of anastomotic leak
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Intraoperative Complications
Injury of the mediastinal visceral pleura
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Bleeding from esophageal branches of the aorta or directly from the aorta
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Bleeding from the azygos vein or cava inferior vein
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Injury of the thoracic duct or the trachea
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Injury of the intercostal arteries posteriorly or the artery of Adamkiewicz (Arteria radicu-
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laris magna)
Postoperative Complications
Pleural eusion and pneumonia
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Anastomotic leakage
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Necrosis of the gastric tube
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Injury to recurrent laryngeal nerve (uni- or bilateral)
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Mediastinitis
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Chylus stula
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Scarring of the esophageal anastomosis with stenosis (long term)
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Section II • Esophagus, Stomach, and Duodenum
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Tricks of the Senior Surgeon
Mobilization of the duodenum, on the one hand, may facilitate the placement of a feeding
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tube. On the other hand, it may include the possibility of shortening the length of the tube to
get a better blood supply of the anastomotic region.
Wide incision of the diaphragm crura provides optimal exposure of the posterior mediasti-
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num to minimize risks of blunt mediastinal dissection.
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Subtotal Esophagectomy: Abdominothoracic Approach
Michael F. Nentwich, Asad Kutup
e goal of the operation is to remove an esophageal tumor with an adequate oncological lymphatic clearance including an upper abdominal D2-lymphadenectomy and radical mediastinal
lymphatic clearance (two-eld lymphadenectomy). Reconstruction is accomplished by gastric
tube formation.
Indications and Contraindications
Indications
Contraindications
1. oracic esophageal carcinoma (cT1sm–cT3)
2. Benign stricture, if transhiatal resection is ill advised (e. g., adherence to trachea).
1. See
▶ Chap. 11 on the transhiatal approach
2. High-risk patients
Preoperative Investigation and Preparation for the Procedure
See ▶ Chap. 11 on the transhiatal approach
Procedure
z Access
Place the patient in the le lateral position for the thoracic part of the operation.
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Anterolateral thoracotomy through the h intercostal space (ICS)
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Reposition the patient in the supine position (see ▶ Chap. 11 on the transhiatal approach).
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Upper transverse incision with median extension (see ▶ Chap. 11 on the transhiatal ap-
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proach)
Alternatively, a modied approach without the need of intraoperative repositioning can be used.
Place the patient on a vacuum-positioning device and establish the right thoracoabdominal
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position as follows:
Rotate the shoulders approximately45°, the hips remain less rotated, and the right arm is
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elevated across the body, exposing the axilla.
Rotate the table for exposure of either abdominal or thoracic parts.
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For the abdominal part, see
▶ Chap. 11 on the transhiatal approach.
P.-A. Clavien, M. G. Sarr, Y. Fong, M. Miyazaki (Eds.), Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surger y,
DOI 10.1007/978-3-662-46546-2_12, © Springer-Verlag Berlin Heidelberg 2016
Section II • Esophagus, Stomach, and Duodenum
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Step 1
Thoracotomy and incision of the pleura along the resection line
Aer thoracotomy through the h ICS (. Fig. 12.1a), position two retractors stepwise. Single
le lung ventilation is performed. e mediastinal pleura is incised along the resection line for
the en-bloc esophagectomy. e incision starts from the pulmonary ligament, circumcising the
dorsal part of the right hilum of the lung and along the right bronchus. It follows the right main
bronchus at the lateral margin of the superior vena cava up to the upper thoracic aperture. en
the incision line changes direction caudally along the right lateral margin of the spine, down to
the diaphragm along the azygos vein. It is of the utmost importance to identify and preserve the
right phrenic nerve (
. Fig. 12.1b).
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. Fig.12.1
Chapter • Subtotal Esophagectomy: Abdominothoracic Approach
Step 2
Division of the pulmonary ligament
For exposure of the pulmonary ligament the lung is pushed cranially and laterally (. Fig. 12.2).
All lymphatic tissue should be moved toward the esophagus. Care has to be taken not to injure
the pulmonary vein to the right lower lobe.
. Fig.12.2
Section II • Esophagus, Stomach, and Duodenum
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Step 3
Ligation of the azygos vein
e superior vena cava and the azygos vein are dissected and the lymph nodes between azygos
vein and the anterior trunk are dissected. Suture ligation toward the vena cava and ligation of the
azygos venal stump are performed (
be performed by using an EndoGIA device.
. Fig.12.3
. Fig. 12.3). Alternatively, transection of the azygos vein can
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Step 4
Radical en bloc lymphadenectomy
Lymphadenectomy starts from the superior vena cava up to the conuence of the two innominate
and subclavian veins. Dissection of the brachiocephalic trunk and right subclavian artery is followed by dissection of the right vagal nerve aer identication of the right recurrent laryngeal
nerve. Caudal to the branching of the recurrent laryngeal nerve, the vagal nerve is transected
and the distal part is pushed toward the en bloc specimen. en lymphadenectomy is performed
continuously along the dorsal wall of the superior vena cava (
. Fig. 12.4).
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. Fig.12.4
Chapter • Subtotal Esophagectomy: Abdominothoracic Approach
Step 4 (continued)
Aerward, the trachea and the right main bronchus are completely freed from lymphatic
tissue. e pre- and paratracheal fat and lymphatic tissue are dissected toward the esophagus
(. Fig. 12.5a).
Dissection of the retrotracheal lymph nodes is then performed. Injury of the membranous
part of the trachea has to be carefully avoided while removing these nodes toward the esophagus
(
. Fig. 12.5b).
. Fig.12.5
Section II • Esophagus, Stomach, and Duodenum
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Step 4 (continued)
Lymph node dissection continues with the upper paraesophageal lymph nodes (. Fig. 12.6a).
All intercostal veins that drain into the azygos vein are ligated and divided. Lymphadenectomy of the subcarinal lymph nodes is then performed with dissection of the le main bronchus
(
. Fig. 12.6b).
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. Fig.12.6
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